Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
NORTH SHORE HEALTH & REHAB FACILITY
LOVELAND, CO · 120 certified beds · Last Life Safety survey May 16, 2024
CMS Certification Number 065129 · first certified July 1975
Ownership
Independently operated (no chain recorded by CMS) · For profit - Limited Liability company
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within CO
30 citations — more than 90% of the 210 certified nursing homes in CO. Compared within CO rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 1 citation; the earlier surveys in the window averaged 14.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Well past the typical window (October 2025 to May 2026), and past the point by which nine in ten CO facilities have been surveyed. This facility’s last Life Safety survey was May 2024. Facilities in CO are typically surveyed 17–24 months after the last one (median 19), measured over 177 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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2 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
2 of the 30 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
3 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 30 Life Safety citations above. The Physical Environment Index
- F-0880 Provide and implement an infection prevention and control program.
How that compares
Compared with the median facility in CO, and nationally. Surveyors differ markedly between states, so the CO figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 30 |
| Median facility in CO | 16 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| March 5, 2019 | 6 |
| March 10, 2020 | 23 |
| May 16, 2024 | 1 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 3 | 2024-05-16 |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | 2 | 2020-03-10 |
| K-0324 | Provide properly protected cooking facilities. | 2 | 2020-03-10 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 1 | 2020-03-10 |
| K-0363 | Install corridor and hallway doors that block smoke. | 1 | 2019-03-05 |
| K-0911 | Meet requirements for the installation and maintenance of electrical systems. | 1 | 2020-03-10 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 1 | 2020-03-10 |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | 1 | 2020-03-10 |
What the citations cover
- Smoke Deficiencies 13
- Gas, Vacuum, and Electrical Systems Deficiencies 6
- Egress Deficiencies 3
- Miscellaneous Deficiencies 3
- Other 5
| Category | Citations |
|---|---|
| Smoke Deficiencies | 13 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 6 |
| Egress Deficiencies | 3 |
| Miscellaneous Deficiencies | 3 |
| Services Deficiencies | 2 |
| Emergency Preparedness Deficiencies | 2 |
| Construction Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
May 16, 2024 — 1 citation
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (June 27, 2024) |
March 10, 2020 — 23 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0036 | Establish emergency prep training and testing. | Deficient, Provider has date of correction (April 24, 2020) |
| E-0037 | Establish staff and initial training requirements. | Deficient, Provider has date of correction (April 24, 2020) |
| K-0161 | Use approved construction type or materials. | Deficient, Provider has date of correction (September 25, 2020) |
| K-0222 | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Deficient, Provider has date of correction (October 24, 2020) |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (October 24, 2020) |
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (October 24, 2020) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (October 28, 2020) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (October 24, 2020) |
| K-0341 | Install a fire alarm system that can be heard throughout the facility. | Deficient, Provider has date of correction (October 24, 2020) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (October 24, 2020) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (October 24, 2020) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (October 24, 2020) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (October 24, 2020) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (October 24, 2020) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (October 24, 2020) |
| K-0711 | Provide a written emergency evacuation plan. | Deficient, Provider has date of correction (October 24, 2020) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (October 24, 2020) |
| K-0908 | Ensure gas and vacuum systems are inspected and tested as part of a maintenance program. | Deficient, Provider has date of correction (October 24, 2020) |
| K-0911 | Meet requirements for the installation and maintenance of electrical systems. | Deficient, Provider has date of correction (October 24, 2020) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (October 24, 2020) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (October 24, 2020) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (October 24, 2020) |
| K-0928 | Ensure equipment listed for use in oxygen-enriched atmospheres are correctly labeled. | Deficient, Provider has date of correction (October 24, 2020) |
March 5, 2019 — 6 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (March 28, 2019) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (April 1, 2019) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (April 1, 2019) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (April 19, 2019) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (April 1, 2019) |
| K-0753 | Have restrictions on the use of highly flammable decorations. | Deficient, Provider has date of correction (April 22, 2019) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.